Enrollment in the insurance exchanges for President Obama’s signature health-care law is at less than half the initial forecast, pushing several major insurance companies to stop offering health plans in certain markets because of significant financial losses.

As a result, the administration’s promise of a menu of health-plan choices has been replaced by a grim, though preliminary, forecast: Next year, more than 1 in 4 counties are at risk of having a single insurer on its exchange, said Cynthia Cox, who studies health reform for the Kaiser Family Foundation.

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In the wake of Aetna’s recent announcement that it was pulling up stakes in 11 of 15 states where it had been selling insurance on Obamacare exchanges, there are more alarming signs that other major insurers are struggling to remain in the game.

On Tuesday, three of the major players in Tennessee — Cigna Health Insurance, Humana and Blue Cross Blue Shield — were granted huge double-digit premium increases for the 2017 season beginning in January amid a warning from the state’s insurance commissioner that the Obamacare markets were “very near collapse.”

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The Affordable Care Act enrollment period doesn’t begin until November, but the recent departure of several health insurance providers from federal and state marketplaces is raising concerns of fewer choices and higher premiums.

But federal officials emphasized that consumers will still have affordable coverage options during a Wednesday conference call. Even if insurance premiums increase by 25 percent, 60 percent of Indiana consumers would be able to purchase coverage for less than $75 per month, according to a report from the U.S. Department of Health and Human Services.

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State insurance officials say they are feeling pressure to approve large ObamaCare premium increases to prevent more insurers losing money from dropping out of the market altogether.

Tennessee’s insurance commissioner, Julie Mix McPeak, this week announced the approval of premium hikes of 62 percent, 46 percent and 44 percent, respectively, for the three insurers on the state’s marketplace.

She said her department’s actuaries had found the rate increases to be justified.

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Three years ago, health economists believed Obamacare’s soon-to-launch marketplaces would grow to replace much of America’s fractured, complex employer-based health insurance system.

Predictions for the employer-sponsored insurance system’s collapse ran rampant. The question around companies shifting workers to the new public marketplaces was often framed not as if but when. University of Pennsylvania’s Zeke Emanuel pegged it at 2025. MIT’s Jonathan Gruber estimated 2050.

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Recently, Avalere worked with the Council for Affordable Health Coverage to examine enrollment trends for the Affordable Care Act (ACA).

Avalere projects that 10.1 million individuals will be enrolled in an exchange plan by the end of 2016. To date, exchange enrollment has not reached original projection numbers. In March 2010, the Congressional Budget Office predicted enrollment figures for 2016 to be at 21 million. Their projections have decreased since then- in January 2016 it was 13 million and in March 2016, it was 12 million. The Obama administration projects 10 million in enrollment for 2016.

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Health insurance startup Oscar Insurance Corp. will reevaluate its approach to Obamacare after suffering significant losses under the U.S. program and will pull out of two markets next year.

Oscar, which pitches itself as a tech-savvy alternative to traditional health insurers, plans to end sales of Affordable Care Act plans in Dallas, a market it entered this year, and New Jersey. It’s part of a more conservative approach by the New York-based company as it plans to introduce insurance products for businesses next year.

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With the fourth open-enrollment period set to begin this fall for the marketplaces set up by the Affordable Care Act, it’s becoming clear that the market for health insurance has not evolved as expected, or hoped.

The market is smaller than projected. The people who have bought health plans overall are sicker than predicted. And health insurers have incurred larger losses than anticipated.

As a result, some large national insurance companies, including UnitedHealthcare, Humana and Aetna, plan to abandon markets across the country next year. And health insurers in Wisconsin are proposing the largest rate increases yet for health plans sold on the online marketplaces throughout the state.

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Increasingly, U.S. consumers may have fewer insurance options under Obamacare.

The latest evidence comes in a study from consulting firm Avalere Health, which examined areas, known as rating regions, that insurers use to set premiums and decide where to offer plans to individuals under the Affordable Care Act.

According to Avalere, 36 percent of the approximately 500 rating regions in the U.S. may have just one health insurer when the 2017 signup season starts on Nov. 1. Another 19 percent could have just two carriers. There was far more competition this year, with about two-thirds of rating areas having three or more health insurers vying for customers’ business, according to Avalere.

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People joked for a while about how insurers were pulling out of Obamacare markets so fast we might end up with areas in which there were no insurers at all.  It’s no joke anymore: with Aetna’s massive withdrawal yesterday from the Affordable Care Act marketplace, Pinal County, Arizona, the third most populated county in that state, currently has no insurers selling policies on the Exchange.  The issue isn’t so much whether people will be subject to the individual mandate tax of up to 2.5% of their income when there are no policies available; an administration that has no difficulty calling a utility shutoff notice a hardship that excuses one from the individual mandate (whether or not the utility was actually shut off) should have no difficulty declaring the non-existence of any insurance to be grounds for an exemption.  The issue is that Pinal County, although a bit of an outlier for now, is a harbinger for fundamental problems with the ACA now manifesting themselves with greater clarity across the country. When an insurer covering over 7% of those in the Exchanges and previously hoping to expand instead drops out, we better look at what is going on.

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